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It’s late. I have come to A&E to clerk in an elderly man who has presented with unsteadiness on his feet and confusion. What I know, and the patient doesn’t, is that the CT scan he’s just had has shown a large tumour in his brain.
It’s probably a secondary from a cancer he thought he was clear of several years ago. I know this, the radiologist knows this, and the A&E doctor who handed him over knows it too.
I’m not sure how to proceed. Firstly, after a bit of negotiation with the A&E nurses, I manage to get the patient into a cubicle and out of the row of trolleys where I had found him. If I have to break bad news, I’ll at least need somewhere private. His daughter is with him and she comes too, carrying a plastic bag with his belongings.
I decide to start from the beginning in the usual way, with a full history and examination. He is a very pleasant man who smiles up at me relentlessly, but seems a bit bemused by my questions. Some of the time he seems to follow me perfectly well, at other times his answers are odd and tangential. His daughter confirms that he has been a bit ‘mixed up’ recently. Also he keeps losing his balance and falling onto his right side.
I work through as much of the neurological examination as is possible. He laughs at me as I try to show him the faces I want him to make to test his seventh cranial nerve, but doesn’t understand I want him to copy me. From a learning point of view, it’s interesting to note the unilateral upgoing plantar, the increased tone and reflexes.
When I’ve finished I summarise what he and his daughter have told me, and ask if he has any idea what might be causing his symptoms. I’ve been hoping that maybe he suspects something bad already, but he shakes his head and shrugs his shoulders in a ‘beats me’ kind of way.
'Well, I’ve had a look at the result of your brain scan. There’s some bad news I’m afraid.'
He doesn’t really respond to this at all, and I can’t work out how much he understands. His daughter just looks exhausted and a bit overwhelmed. I start to wonder if it’s the right time and place to do this. So I offer them the choice - I can tell them about it now or it can wait until the morning, when they’ve had some sleep and his wife and the rest of the family can be there.
They decide to wait. I feel bad that this will make it someone else’s job to break the news, but it seems the kindest thing to do.
In the meantime, it seems strange to have this knowledge, so intimate, so devastating, about a man I hadn’t even met an hour ago. It seems strange that he himself can be unaware of it. It’s an unwanted secret I carry around with me for the rest of the night.
Why didn't you just offer the information up front - before exhausting them with the questioning when you already has all the information and diagnosis?
Over a period of years, I have learnt to stay detached emotionally and be truthful to give the whole findings bad or good.
The one that burdened me the most was a girl with testicular feminisation (now called complete androgen insensitivity) who told me her ovaries needed to be removed when she was young, so was unaware of the nature of her condition. I had access to all the letters in her notes which felt like a dreadful secret to have to hold on to even though it could have been kinder for her not to know.
Best to tell the pt/family when you know & not put it off - I always put myself in their position what would you want answer generally I would want to know one way or the other.
Suggest you try not to 'carry it around with you for the rest of the night' it will ultimately grind you down. I agree with the comments by anonymous (29th Oct) you really must learn to stay emotionally detatched
Experienced (ie old) H&N surgeon